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Fuller and Forbes Partnership

Advanced Clinical Practitioner Discharge to Assess (Pathway 2)

The closing date is 22 August 2025

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Job summary

The Discharge to Assess (D2A) Pathway 2 wasacquired by the Fuller and Forbes Partnership 18 months ago.

We are looking for applicants whowill work alongside a team of GPs to deliver high-quality, patient-centered clinical care to individuals discharged from hospital into a Pathway 2 Discharge to Assess placement and who require short-term support & assessment of needs in a bedded rehabilitation setting.

Main duties of the job

The ACP will operate autonomously, managing full clinical episodes, assessing patients on registering with the service, managing periods of chronic or acute illness, diagnosing conditions, prescribing treatments, coordinating ongoing care, and supporting discharge planning. This role is crucial to ensuring timely, effective transitions of care from hospital to community and eventually to home or long-term care.

About us

Recently acquired by the Fuller and Forbes partnership,the DTA team is part of Mayflower Medical Group which is a collection of 5 GP Surgeries based across Plymouth. Our surgeries provide healthcare to 35,000 patients at the following locations Stirling Road, Ernesettle, Trelawny, Mannamead and Mount Gould.

As a group, our vision is to enable patients to live longer and healthier lives that are full, active and meaningful. We aim to do this by developing a sustainable primary healthcare service. Our service is undertaken by our vast multidisciplinary team of GPs, Advanced Clinical Practitioners, Pharmacists, Paramedics and Nursing teams, as well as our PCN staff.

Details

Date posted

08 August 2025

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time

Reference number

A2381-25-0021PLY

Job locations

Mayflower Medical Group

Stirling Road

Plymouth

PL5 1PL


Job description

Job responsibilities

Key Responsibilities:

- Provide advanced assessment and clinical decision-making for potentially unstable patients newly transferred to D2A Pathway 2 beds.

- Responsible for the assessment & treatment of both, physical and mental health needs of the individual.

- Develop, initiate, and evaluate treatment plans and prescribing (if qualified).

- Monitor and respond to changes in patient condition, escalating appropriately.

- Collaborate with external multidisciplinary teams including physiotherapists, occupational therapists, social care teams, and discharge coordinators.

- conduct clinical reviews within the D2A setting.

- Support timely, safe discharge decisions and onward referrals.

- Undertake comprehensive initial assessments (CGA), ensuring accurate documentation and risk stratification.

- Create personalised care plans and ensure effective communication with DTA bedded providers.

- Facilitate safe discharge planning in collaboration with external providers, families, reablement teams, and social services.

- Act as a senior clinical leader within the D2A GP Service.

- Support the development and refinement of D2A care pathways to enhance flow and patient outcomes.

- Contribute to rota development and clinical cover planning.

- Participate in service audits and outcome tracking.

- Provide supervision, clinical mentorship and pastoral support to other team members.

- Deliver informal and formal teaching on assessment and care planning in D2A settings.

- Participate in audit and quality assurance projects, particularly around readmission prevention and discharge safety.

- Implement evidence-based interventions to improve outcomes and reduce length of stay.

Job description

Job responsibilities

Key Responsibilities:

- Provide advanced assessment and clinical decision-making for potentially unstable patients newly transferred to D2A Pathway 2 beds.

- Responsible for the assessment & treatment of both, physical and mental health needs of the individual.

- Develop, initiate, and evaluate treatment plans and prescribing (if qualified).

- Monitor and respond to changes in patient condition, escalating appropriately.

- Collaborate with external multidisciplinary teams including physiotherapists, occupational therapists, social care teams, and discharge coordinators.

- conduct clinical reviews within the D2A setting.

- Support timely, safe discharge decisions and onward referrals.

- Undertake comprehensive initial assessments (CGA), ensuring accurate documentation and risk stratification.

- Create personalised care plans and ensure effective communication with DTA bedded providers.

- Facilitate safe discharge planning in collaboration with external providers, families, reablement teams, and social services.

- Act as a senior clinical leader within the D2A GP Service.

- Support the development and refinement of D2A care pathways to enhance flow and patient outcomes.

- Contribute to rota development and clinical cover planning.

- Participate in service audits and outcome tracking.

- Provide supervision, clinical mentorship and pastoral support to other team members.

- Deliver informal and formal teaching on assessment and care planning in D2A settings.

- Participate in audit and quality assurance projects, particularly around readmission prevention and discharge safety.

- Implement evidence-based interventions to improve outcomes and reduce length of stay.

Person Specification

Qualifications

Essential

  • - Registered Nurse, Paramedic, AHP or other regulated profession, with Advanced Practice MSc or equivalent.
  • - Independent prescriber.
  • - Significant clinical experience in primary care, acute care,
  • rehabilitation, intermediate care, or complex discharge pathways.
  • - Strong autonomous assessment and diagnostic skills.
  • - Excellent communication and multidisciplinary co-ordination abilities.
  • - Skilled in using SystmOne clinical system.

Desirable

  • - Prior experience in Discharge to Assess or primary care setting.
  • - Qualification or extensive experience in frailty, geriatric assessment, chronic disease management in a primary care setting.
  • - Familiarity with CHC assessments and safeguarding procedures.
  • - Leadership experience in a primary or secondary care setting.
Person Specification

Qualifications

Essential

  • - Registered Nurse, Paramedic, AHP or other regulated profession, with Advanced Practice MSc or equivalent.
  • - Independent prescriber.
  • - Significant clinical experience in primary care, acute care,
  • rehabilitation, intermediate care, or complex discharge pathways.
  • - Strong autonomous assessment and diagnostic skills.
  • - Excellent communication and multidisciplinary co-ordination abilities.
  • - Skilled in using SystmOne clinical system.

Desirable

  • - Prior experience in Discharge to Assess or primary care setting.
  • - Qualification or extensive experience in frailty, geriatric assessment, chronic disease management in a primary care setting.
  • - Familiarity with CHC assessments and safeguarding procedures.
  • - Leadership experience in a primary or secondary care setting.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Additional information

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Fuller and Forbes Partnership

Address

Mayflower Medical Group

Stirling Road

Plymouth

PL5 1PL


Employer's website

http://bramleyonline.co.uk/ (Opens in a new tab)

Employer details

Employer name

Fuller and Forbes Partnership

Address

Mayflower Medical Group

Stirling Road

Plymouth

PL5 1PL


Employer's website

http://bramleyonline.co.uk/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

Advanced Clinical Practitioner

Simon Jones

simon.jones27@nhs.net

Details

Date posted

08 August 2025

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time

Reference number

A2381-25-0021PLY

Job locations

Mayflower Medical Group

Stirling Road

Plymouth

PL5 1PL


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